Clinical presentation and treatment of distal anterior inferior cerebellar artery aneurysms.

Aneurysms located at the distal portion of the anterior inferior cerebellar artery (AICA) are rare, and their clinical features are not fully understood. We report the clinical features and management of nine distal AICA aneurysms in nine patients treated during the past decade at Kagoshima University Hospital and affiliated hospitals. Our series includes seven women and two men. Of their nine aneurysms, eight were ruptured and one was unruptured; six were saccular and three were dissecting aneurysms. The most prevalent location was the meatal loop (n = 5) followed by the postmeatal (n = 3) and premeatal segment (n = 1) of the AICA, suggesting hemodynamic stress as an etiology of these distal AICA aneurysms. Of the nine patients, five presented with angiographic features suggestive of increased hemodynamic stress to the AICA and the common trunk of the posterior inferior cerebellar artery, with vertebral artery stenosis, marked laterality, and a primitive hypoglossal artery. We addressed eight aneurysms (eight patients) surgically; one aneurysm in one patient disappeared in the course of 3 months without surgical treatment. Of the eight surgically treated aneurysms, seven were ruptured and one was unruptured, five were clipped via lateral suboccipital craniotomy, two were trapped via lateral suboccipital craniotomy, and one was embolized. Good outcomes were obtained in six of the eight patients who underwent operation (75 %). We consider increased hemodynamic stress attributable to anatomic variations in the AICA and related posterior circulation to be the predominant contributor to the development of distal AICA aneurysms. Direct clipping and trapping yielded favorable outcomes in our series.

TLR4, IL-6, IL-18, MyD88 and HMGB1 are highly expressed in intracranial inflammatory lesions and the IgG4/IgG ratio correlates with TLR4 and IL-6.

We determined distribution of plasma cells and IgG4/IgG index and factors associated with the index in intracranial inflammatory lesions. Specimens of nine patients were analyzed immunohistochemically using antibodies against CD45, CD68, CD3, CD4, CD8, CD20, CD138, lambda chain, kappa chain, IgG, IgG4, IL-1α, IL-6, IL-18, toll-like receptor (TLR) 2, TLR4, high-mobility group box 1 (HMGB1), tumor necrosis factor-alpha (TNF-α), myeloid differentiation factor 88 (MyD88), and anaplastic lymphoma kinase (ALK). The relationship between all the factors was assessed using Spearman's rank correlation coefficient (ρ). Negative ALK staining was observed in all the patients. Plasma cells were detected in eight patients with varying degrees. The highest number of neutrophils, but no plasma cells, was observed in a patient with the shortest history of inflammation. IgG4/IgG index was independent of the number of plasma cells. The index was relatively highly correlated with IL-6 (ρ = 0.7271) and TLR4 expression (ρ = 0.7246). IL-6 expression was highly correlated with TLR4 expression (ρ = 0.8042). IL-18 was maximally expressed in all the patients. TLR4 expression was strong, but TRL2 expression was weak. Positive HMGB1 staining was observed in all the patients, predominantly in the nuclei, but also in the cytoplasm in four patients. The cytoplasmic expression strongly correlated with IL-1α expression (ρ = 0.9583). The cytoplasmic colocalization of HMGB1 and IL-1α was histologically confirmed in cells with collapsing nuclei by the double-staining method. The IgG4/IgG indexes varied case by case. IL-6 and TLR4 expressions may influence IgG4/IgG index. The nuclei of cells with both IL-1α and HMGB1 expressions in the cytoplasm collapse in the cell death stage. The cooperative high expression of TLR4, IL-6, IL-18, MyD88 and HMGB1 suggest their critical roles in the inflammation circuit.

Clinical presentation and treatment of distal posterior inferior cerebellar artery aneurysms.

Aneurysms located at the distal portion of the posterior inferior cerebellar artery (PICA) are rare, and their clinical features are not fully understood. We report the clinical features and management of 30 distal PICA aneurysms in 28 patients treated during the past decade at Kagoshima University Hospital and affiliated hospitals. Our series includes 20 women and eight men. Of their 30 aneurysms, 24 were ruptured, and six were unruptured; there were 27 saccular and two fusiform aneurysms; one was dissecting. Their location was at the anterior-medullary (n = 4), lateral-medullary (n = 9), tonsillomedullary (n = 7), telovelotonsillar (n = 6), and cortical (n = 4) segment of the PICA. In 18 patients, angiographic features suggested hemodynamic stress including an absent contralateral PICA or ipsilateral anterior inferior cerebellar artery, termination of the vertebral artery (VA) at the PICA, and hyperplasia or occlusion of the contralateral VA. As three patients died before surgery, 27 aneurysms in 25 patients were surgically treated. Of these, 6 were unruptured aneurysms; 20 were clipped via midline or lateral suboccipital craniotomy, and 5 were embolized with Guglielmi coils; in one, the PICA flow was reconstructed by OA-PICA anastomosis, and in the other one, the PICA was resected. Of the 25 surgically treated patients, 22 (88%) had good outcomes. The predominant contributor to the development of distal PICA aneurysms is thought to be increased hemodynamic stress attributable to anomalies in the PICA and related posterior circulation. Both direct clipping and coil embolization yielded favorable outcomes in our series. However, considering the difficulties that may be encountered at direct clipping in the acute stage and the availability of advanced techniques and instrumentation, aneurysmal coiling is now the first option to address these aneurysms.

Clinical implications of associated venous drainage in patients with cavernous malformation.

OBJECT: The authors reviewed angiograms obtained in patients with cavernous malformations to identify and characterize coexisting venous drainage. METHODS: Fifty-seven patients with cavernous malformations treated at the authors' institutions between 1994 and 2002 were classified into three groups according to the venous system adjacent to the malformation on angiography studies. In Group A patients (23 patients) the malformations had no venous drainage; in Group B patients (14 patients) the lesions were associated with typical venous malformations; and in Group C patients (20 patients) the lesions had atypical venous drainage (AVD). The risk of hemorrhage based on the type of associated venous drainage was analyzed, and the usefulness of magnetic resonance (MR) imaging compared with digital subtraction (DS) angiography in demonstrating associated AVD was determined. Fifty-seven patients harbored 67 cavernous malformations: Group A patients had 29 cavernous malformations with no associated venous drainage; Group B patients had 17 lesions associated with venous malformations; and Group C patients harbored 21 lesions, 20 of which manifested AVD. Symptomatic hemorrhage was present in 10 (43.5%) of 23 Group A patients and in 28 (82.4%) of 34 Groups B and C patients. Although high-resolution MR imaging revealed the presence of associated venous malformations in 11 (78.6%) of 14 Group B patients, such studies demonstrated AVD in only two (10%) of 20 Group C patients. CONCLUSIONS: Patients harboring cavernous malformations plus venous malformations or AVD are more likely to present with symptomatic hemorrhage than are patients with cavernous malformation alone. The actual incidence of associated venous drainage may be underestimated when MR imaging alone is used rather than combined with DS angiography.

Pontine malignant astrocytoma with hemorrhagic onset--case report.

A 7-year-old boy presented with acute onset of left hemiparesis and headache, followed by disturbance of consciousness. Neuroimaging studies showed pontine hemorrhage. Surgery was performed to remove a massive hematoma. Histological examination of the wall revealed anaplastic astrocytoma. Postoperative radiation therapy and several types of chemotherapy were administered. However, the tumor recurred and he died 9 months after onset. Hemorrhagic onset of pontine glioma is rare and carries an extremely poor prognosis.

Novel Guglielmi detachable coils (GDCs) for the treatment of brain aneurysms. In vitro study of hydroxyapatite coating on Pt plate as GDCs model.

With the use of an alternate soaking process a thin layer of hydroxyapatite (HAp) was formed on a platinum plate (Pt plate) which was used as a model for Guglielmi detachable coils (GDCs). The in vitro coagulant activity of the HAp-coated Pt plate was evaluated for the purpose of brain aneurysm treatment. In order to fix and to form the apatite layer homogeneously, beta-mercaptopropionic acid was immobilized onto the Pt surface prior to use. The HAp layer was formed on the beta-mercaptopropionic acid-fixed Pt plate surface, and quantitative control of apatite formation was achieved by controlling the number of alternate soaking process cycles. The HAp formed on the Pt plate surface was confirmed by X-ray diffraction and X-ray photoelectron spectroscopy studies. Blood interaction with the Pt plate was altered from nonthrombotic to highly thrombotic by forming a HAp layer on the surface. The alternate soaking process is an appropriate method to modify the GDCs. Complete treatment of brain aneurysms is expected with the use of HAp-coated GDCs, which would allow formation of a stable blood clot.